Restless legs syndrome (RLS) is a sleep disorder in which a person experiences unpleasant sensations in the legs described as creeping, crawling, tingling, pulling, or painful. These sensations usually occur in the calf area but may be felt anywhere from the thigh to the ankle. One or both legs may be affected; for some people, the sensations are also felt in the arms. These sensations occur when the person with RLS lies down or sits for prolonged periods of time, such as at a desk, riding in a car, or watching a movie. People with RLS describe an irresistible urge to move the legs when the sensations occur. Usually, moving the legs, walking, rubbing or massaging the legs, or doing knee bends can bring relief, at least briefly.

RLS symptoms worsen during periods of relaxation and decreased activity. RLS symptoms also tend to follow a set daily cycle, with the evening and night hours being more troublesome for RLS sufferers than the morning hours. People with RLS may find it difficult to relax and fall asleep because of their strong urge to walk or do other activities to relieve the sensations in their legs. Persons with RLS often sleep best toward the end of the night or during the morning hours. Because of less sleep at night, people with RLS may feel sleepy during the day on an occasional or regular basis. The severity of symptoms varies from night to night and over the years as well. For some individuals, there may be periods when RLS does not cause problems, but the symptoms usually return. Other people may experience severe symptoms daily.

Many people with RLS also have a related sleep disorder called periodic limb movements in sleep (PLMS). PLMS is characterized by involuntary jerking or bending leg movements during sleep that typically occur every 10 to 60 seconds. Some people may experience hundreds of such movements per night, which can wake them, disturb their sleep, and awaken bed partners. People who have RLS and PLMS have trouble both falling asleep and staying asleep and may experience extreme sleepiness during the day. As a result of problems both in sleeping and while awake, people with RLS may have difficulties with their job, social life, and recreational activities.

Common Characteristics of Restless Legs Syndrome

Some common symptoms of RLS include:

Unpleasant sensations in the legs (sometimes the arms as well), often described as creeping, crawling, tingling, pulling, or painful;

Leg discomfort occurs when lying down or sitting for prolonged periods of time;

The symptoms are worse in the evening and during the night.

Other possible characteristics include:

Involuntary leg (and occasionally arm) movements while asleep;

Difficulty falling asleep or staying asleep;

Sleepiness or fatigue during the daytime;

Cause of the leg discomfort not detected by medical tests;

Family members with similar symptoms.

Restless Legs Syndrome (RLS)

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Last Updated: April 4, 2005

Treatment Overview

Treatment for restless legs syndrome is based on the type and severity of your symptoms. Getting regular exercise and enough sleep may relieve mild symptoms. Medications may be tried when symptoms are severe and interfere with sleep and daily functioning. If your symptoms are being caused by another medical condition (such as iron-deficiency anemia), that condition can be treated first.

Initial treatment

Changing your daily routine is sometimes enough to control your symptoms. Stretching, walking, exercising regularly, taking a hot or cold bath, using massage, and avoiding smoking and caffeine may reduce or control your symptoms.

Restless legs syndrome that develops during pregnancy usually goes away soon after the baby's delivery, most often within days. Your doctor may recommend conservative treatment, such as regular exercise and stretching, to relieve symptoms. Your condition may be reevaluated if it persists after you have given birth.

Children with restless legs syndrome are not usually treated with drugs right away. Instead, regular, moderate exercise and regular sleep routines are tried first. If this treatment is not effective, the doctor may prescribe drugs—such as levodopa or dopamine agonists—that help increase a chemical in the brain called dopamine, to control involuntary leg movements. Clonidine, a drug that is usually used to treat high blood pressure, has also been used to treat restless legs syndrome in children.

Ongoing treatment

If your symptoms are mild, you will probably be able to control the uncomfortable sensations and urges to move your legs through regular exercise, stretching, walking, losing weight if you are overweight, and by avoiding smoking and caffeine. Sometimes a hot or cold bath or massage can help. If your doctor determines that your restless legs syndrome is caused by another condition (such as diabetes or iron-deficiency anemia), treating that condition will usually resolve your symptoms.

If your symptoms do not improve, drugs may be used to control involuntary leg movements and help you sleep, such as: 1

Opioids, such as oxycodone (Percocet), hydrocodone (Lortab) and tramadol (Ultram).

Anticonvulsants, such as gabapentin (Neurontin), which are sometimes used if dopamine agonists or opioids do not improve symptoms.

In addition, your doctor may prescribe benzodiazepines, alone or in combination with dopamine agonists, opioids, or anticonvulsants.

Medications are started at the lowest effective dose. Sometimes doses are split, although both are usually taken in the evening. Sometimes drugs are combined to better control symptoms and manage side effects.

If your doctor recommends medication, make sure to discuss expectations and that you understand the potential benefits and risks of the drug. Let your doctor know about all of the other drugs you are taking. Drugs taken for other conditions sometimes contribute to restless legs syndrome. For example, antidepressants improve restless legs syndrome in some people and make it worse in others.

Treatment if the condition gets worse

If you continue to have symptoms even though you are receiving treatment with drugs and are exercising regularly, eating right, and not smoking or using caffeine, your symptoms may need to be reevaluated. Many other conditions can cause the sensations found in restless legs syndrome, including several vitamin and mineral deficiencies.

Your doctor may recommend different drugs or a combination of drugs. Follow up with your doctor if your symptoms do not improve.

Treatment for restless legs syndrome is based on the type and severity of your symptoms. Getting regular exercise and enough sleep may relieve mild symptoms. Medications may be tried when symptoms are severe and interfere with sleep and daily functioning. If your symptoms are being caused by another medical condition (such as iron-deficiency anemia), that condition can be treated first.

Initial treatment

Changing your daily routine is sometimes enough to control your symptoms. Stretching, walking, exercising regularly, taking a hot or cold bath, using massage, and avoiding smoking and caffeine may reduce or control your symptoms.

If your symptoms are caused by another medical condition such as diabetes or iron-deficiency anemia, you will be treated for that condition first. For example, if iron deficiency is causing restless legs syndrome, you will be prescribed iron supplements.

Restless legs syndrome that develops during pregnancy usually goes away soon after the baby's delivery, most often within days. Your doctor may recommend conservative treatment, such as regular exercise and stretching, to relieve symptoms. Your condition may be reevaluated if it persists after you have given birth.

Children with restless legs syndrome are not usually treated with drugs right away. Instead, regular, moderate exercise and regular sleep routines are tried first. If this treatment is not effective, the doctor may prescribe drugs—such as levodopa or dopamine agonists—that help increase a chemical in the brain called dopamine, to control involuntary leg movements. Clonidine, a drug that is usually used to treat high blood pressure, has also been used to treat restless legs syndrome in children.

Ongoing treatment

If your symptoms are mild, you will probably be able to control the uncomfortable sensations and urges to move your legs through regular exercise, stretching, walking, losing weight if you are overweight, and by avoiding smoking and caffeine. Sometimes a hot or cold bath or massage can help. If your doctor determines that your restless legs syndrome is caused by another condition (such as diabetes or iron-deficiency anemia), treating that condition will usually resolve your symptoms.

If your symptoms do not improve, drugs may be used to control involuntary leg movements and help you sleep, such as: 1

Opioids, such as oxycodone (Percocet), hydrocodone (Lortab) and tramadol (Ultram).

Anticonvulsants, such as gabapentin (Neurontin), which are sometimes used if dopamine agonists or opioids do not improve symptoms.

In addition, your doctor may prescribe benzodiazepines, alone or in combination with dopamine agonists, opioids, or anticonvulsants.

Medications are started at the lowest effective dose. Sometimes doses are split, although both are usually taken in the evening. Sometimes drugs are combined to better control symptoms and manage side effects.

If your doctor recommends medication, make sure to discuss expectations and that you understand the potential benefits and risks of the drug. Let your doctor know about all of the other drugs you are taking. Drugs taken for other conditions sometimes contribute to restless legs syndrome. For example, antidepressants improve restless legs syndrome in some people and make it worse in others.

Treatment if the condition gets worse

If you continue to have symptoms even though you are receiving treatment with drugs and are exercising regularly, eating right, and not smoking or using caffeine, your symptoms may need to be reevaluated. Many other conditions can cause the sensations found in restless legs syndrome, including several vitamin and mineral deficiencies.

Your doctor may recommend different drugs or a combination of drugs. Follow up with your doctor if your symptoms do not improve.

Overview

Restless legs syndrome (RLS) is a condition in which your legs feel extremely uncomfortable while you're sitting or lying down. It usually makes you feel like getting up and moving around. When you do so, the unpleasant feeling of restless legs syndrome goes away.

Restless legs syndrome affects both sexes, can begin at any age and may worsen as you get older. Restless legs syndrome can disrupt sleep — leading to daytime drowsiness — and make traveling difficult.

A number of simple self-care steps and lifestyle changes may benefit you. Medications also help many people with restless legs syndrome.

Signs and symptoms

People typically describe the unpleasant sensations of restless legs syndrome as "deep-seated, creeping, crawling, jittery, tingling, burning or aching" feelings in their calves, thighs, feet or arms. Sometimes the sensations seem to defy description. People usually don't describe the condition as a muscle cramp or numbness. Common characteristics of the signs and symptoms include:

Origination during inactivity. The sensation typically begins while you're lying down or sitting for an extended period of time, such as in a car, airplane or movie theater.

Relief by movement. The sensation of RLS lessens if you get up and move. People combat the sensation of restless legs in a number of ways — by stretching, jiggling their legs, pacing the floor, exercising or walking. This compelling desire to move is what gives restless legs syndrome its name.

Worsening of symptoms in the evening. Symptoms typically are less bothersome during the day and are felt primarily at night.

Nighttime leg twitching. RLS is associated with periodic limb movements of sleep (PLMS). Doctors used to call this condition myoclonus, but now they refer to it as PLMS. With PLMS you involuntarily flex and extend your legs while sleeping — without being aware you're doing it — often resulting in a restless night's sleep for your bed partner. Hundreds of these twitching or kicking movements may occur throughout the night. If you have severe RLS, these involuntary kicking movements may also occur while you're awake. PLMS is common in older adults, even without RLS, and doesn't always disrupt sleep. More than four out of five people with RLS also experience PLMS.

Most people with RLS find it difficult to get to sleep or stay asleep. Insomnia may lead to excessive daytime drowsiness, but RLS may prevent you from enjoying a daytime nap.

Although restless legs syndrome doesn't lead to other serious conditions, symptoms can range from bothersome to incapacitating. In fact, it's common for symptoms to fluctuate in severity, and occasionally symptoms disappear for periods of time.

RLS can develop at any age, even during childhood. Many adults who have RLS can recall being told as a child that they had growing pains or can remember parents rubbing their legs to help them fall asleep. The disorder is more common with increasing age.

In many cases, no known cause for restless legs syndrome exists. Researchers suspect the condition may be due to an imbalance of the brain chemical dopamine. This chemical sends messages to control muscle movement.

Restless legs syndrome runs in families in up to half of people with RLS, especially if the condition started at an early age. Researchers have identified sites on the chromosomes where genes for RLS may be present.

Stress tends to worsen the symptoms of RLS. Pregnancy or hormonal changes may temporarily worsen RLS signs and symptoms. Some women experience RLS for the first time during pregnancy, especially during their last trimester. However, for most of these women, signs and symptoms usually disappear about a month after delivery.

For the most part, restless legs syndrome isn't related to a serious underlying medical problem. However, RLS sometimes accompanies other conditions, such as:

Peripheral neuropathy. This damage to the nerves in your hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism.

Iron deficiency. Even without anemia, iron deficiency can cause or worsen restless legs syndrome. If you have a history of bleeding from your stomach or bowels, experience heavy menstrual periods or repeatedly donate blood, you may have iron deficiency.

Kidney failure. If you have kidney failure, you also may have iron deficiency. When the kidney fails to function properly, iron stores in your blood can decrease. This, along with other changes in body chemistry, may cause or worsen RLS.

Some people with RLS never seek medical attention because they worry that their symptoms are too difficult to describe or won't be taken seriously. Some doctors wrongly attribute symptoms to nervousness, stress, insomnia or muscle cramps. But restless legs syndrome has received more media attention and focus from the medical community in recent years, making more people aware of the condition.

If you think you may have RLS, consult your family doctor. Doctors diagnose RLS by listening to your description of your symptoms and by reviewing your medical history. Your doctor will ask you questions such as:

Do you experience unpleasant or creepy, crawly sensations in your legs, tied to a strong urge to move?

Does movement help relieve the sensations?

Are you more bothered by these sensations when sitting or at night?

Do you often have trouble falling asleep or staying asleep?

Have you been told that you jerk your legs, or your arms, when asleep?

Is anyone else in your family bothered by restless legs?

There's no blood or lab test specifically for the diagnosis of RLS. Your answers help your doctor clarify whether you have RLS or whether testing is needed to rule out other conditions that may explain your symptoms. Blood tests or muscle or nerve studies may be necessary to pinpoint a cause.

Your doctor may refer you to a sleep specialist for additional evaluation. This may require that you stay overnight at a sleep clinic, where doctors can study your sleep habits closely and check for leg twitching (periodic limb movements) during sleep — a possible sign of restless legs syndrome. However, a diagnosis of RLS usually doesn't require a sleep study.

Sometimes, treating an underlying condition such as iron deficiency or peripheral neuropathy greatly relieves symptoms of RLS. Correcting the iron deficiency may involve taking iron supplements. However, take iron supplements only under medical supervision and after your doctor has checked your blood iron level.

If you have restless legs syndrome without any associated condition, treatment focuses on lifestyle changes and medications. Several prescription medications, most of which were developed to treat other diseases, are available to reduce the restlessness in your legs. These include:

Medications for Parkinson's disease. These medications reduce the amount of motion in your legs by affecting the level of the chemical messenger dopamine in your brain. They include pramipexole (Mirapex), pergolide (Permax), ropinirole (Requip), and a combination of carbidopa and levodopa (Sinemet). However, people with RLS are at no greater risk of developing Parkinson's disease than are those without RLS.

Opioids. Narcotic medications can relieve mild to severe symptoms, but they may be addicting if used in too high doses. Some examples include codeine, the combination medicine oxycodone and acetaminophen (Percocet, Roxicet), and the combination medicine hydrocodone and acetaminophen (Vicodin, Duocet).

Muscle relaxants and sleep medications. This class of medications, known as benzodiazepines, helps you sleep better at night. But these medications don't eliminate the leg sensations, and they may cause daytime drowsiness. Commonly used sedatives for RLS include clonazepam (Klonopin), eszopiclone (Lunesta), ramelteon (Rozerem), temazepam (Restoril, Razapam), zaleplon (Sonata) and zolpidem (Ambien).

Medications for epilepsy. Certain epilepsy medications, such as gabapentin (Neurontin), may work well for some people with RLS.

It may take several trials for you and your doctor to find the right medication and dosage for you. A combination of medications may work best.

One caveat with drugs to treat RLS is that sometimes a medication that has worked for you for a while to relieve symptoms becomes ineffective. Or you notice your symptoms returning earlier in the day. For example, if you have been taking your medication at 8 p.m., your symptoms of RLS may start occurring at 6 p.m. This is called augmentation. Your doctor may substitute another medication to combat the problem.

Most of the drugs prescribed to treat RLS aren't recommended for pregnant women. Instead, your doctor may recommend self-care techniques to relieve symptoms. However, if the sensations are particularly bothersome during your last trimester, your doctor may OK the use of pain relievers.

Some medications may worsen symptoms of RLS. These include antinausea drugs, calcium channel blockers (which are used to treat heart conditions) and most antidepressants. Your doctor may recommend that you avoid these medications if possible. However, should you need to take these medications, restless legs can still be controlled by adding drugs that manage the condition.

Self-care

Making simple lifestyle changes can play an important role in alleviating symptoms of RLS. These steps may help reduce the extra activity in your legs:

Take pain relievers. For very mild symptoms, taking an over-the-counter pain reliever such as ibuprofen (Advil, Motrin, others) when symptoms begin may relieve the twitching and the sensations.

Apply warm or cool packs. You may find that the use of heat or cold, or alternating use of the two, lessens the sensations in your limbs.

Try relaxation techniques, such as meditation or yoga. Stress can aggravate RLS. Learn to relax, especially before going to bed at night.

Establish good sleep hygiene. Fatigue tends to worsen symptoms of RLS, so it's important that you implement a program of good sleep hygiene. Ideally, sleep hygiene involves having a cool, quiet and comfortable sleeping environment, going to bed at the same time every night, arising at the same time every morning, and obtaining a sufficient number of hours of sleep to feel well rested. Some people with RLS find that going to bed later and arising later in the day helps to obtain an adequate amount of sleep.

Exercise. Getting moderate, regular exercise may relieve symptoms of RLS, but overdoing it at the gym or working out too late in the evening may intensify symptoms.

Avoid caffeine. Sometimes cutting back on caffeine may help restless legs. It's worth trying to avoid caffeine-containing products, including chocolate and caffeinated beverages such as coffee, tea and soft drinks, for a few weeks to see if this helps.

Cut back on alcohol and tobacco. These substances also may aggravate or trigger symptoms of RLS. Test to see whether avoiding them helps.

Stay mentally alert in the evening. Boredom and drowsiness before bedtime may worsen RLS.

Leg massage may work to calm restless legs. A warm bath or an over-the-counter pain reliever such as ibuprofen before bed also may help. For severely bothersome cases, you may need prescription medication for symptom relief.

Restless legs syndrome is generally a lifelong condition. Living with RLS involves developing coping strategies that work for you. The Restless Legs Syndrome Foundation recommends these approaches:

Talk about RLS. Sharing information about RLS will help your family members, friends and co-workers better understand when they see you pacing the halls, standing at the back of the theater, or walking to the water cooler many times throughout the day.

Don't fight it. If you attempt to suppress the urge to move, you may find that your symptoms only get worse. Get out of bed. Find an activity that's distracting. Stop frequently when traveling.

Keep a sleep diary. If you can't sit to write, dictate into a small tape recorder. Keep track of the medications and strategies that help or hinder your battle with RLS, and share this information with your doctor.

Rise to new levels. You may be more comfortable if you elevate your desktop or bookstand to a height that will allow you to stand while you work or read.

Stretch out your day. Begin and end your day with stretching exercises or gentle massage.

Seek help. Support groups bring together family members and people with RLS. By participating in a group, your insights not only can help you but also may help someone else.